Laparoscopic liver surgery for everyone: The hybrid method

doi:10.1016/j.surg.2007.08.006

Surgery

Volume 142, Issue 4, October 2007, Pages 463-468.e2

https://doi.org/10.1016/j.surg.2007.08.006 Get rights and content

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.

Section snippets

Case 1

A 57-year-old man with chronic autoimmune hepatitis and multiple comorbidities presents with a 2-cm lesion in the posterior right lobe of the liver radiologically consistent with hepatocellular carcinoma (Fig 1, left panel). He is not a candidate for liver transplantation because of his comorbidities. Alpha-fetoprotein level is within the normal range.

Case 2

A 48-year-old man with well-compensated cirrhosis secondary to chronic hepatitis C infection presents with a 2-cm lesion in the left lateral

Technique

A beanbag should be used to ensure that the patient remains secure on the operating table despite extreme rotation. Once the patient is positioned (supine), prepared in the usual manner, an epigastric incision is made 2 cm below the xiphoid process. The incision should be large enough to accommodate the surgeon’s hand through a hand-port but small enough to prevent leakage of CO₂ around the hand-port. The incision is made in the usual open manner. The surgeon (right-handed) stands on the left

Methods

We retrospectively reviewed the hospital charts (with approval from the Institutional Review Board) of patients who had undergone the hybrid method at Northwestern Memorial Hospital between January 2004 and July 2006. To assess safety and efficacy, we compared these cases with contemporaneous resections that included pure laparoscopic, hand-assisted laparoscopic, and open cases. We chose consecutive cases that matched for the type of resection performed. We also selected matched cases for

Results

We evaluated 8 distinct groups of patients undergoing liver resection at our institution between July 2001 and July 2006. There were 4 types of procedures performed: 1) open resection, 2) hybrid (laparoscopy-assisted), 3) hand-assisted laparoscopic resection, and 4) pure laparoscopic resection. For each group, we included both lobar and segmental resections. The study group (group 2) was compared with consecutive, case-matched, contemporaneous controls (groups 1, 3, and 4) in terms of operative

Discussion

The advent of minimally invasive surgery has resulted in the application of laparoscopic techniques to liver surgery for both benign and malignant liver lesions. The first application of laparoscopic liver surgery to the liver consisted of wedge liver biopsies in the staging of lymphoma,¹² followed by laparoscopic wedge resections.13, 14 More recently, reports of anatomic lobectomies have emerged.15, 16 Although some surgeons have advocated using a pure laparoscopic approach to these patients,17

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Cited by (77)

Minimally Invasive Techniques of Hepatic Resection
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
As liver resection becomes safer and experience in minimal access surgery accumulates, minimally invasive hepatectomy is gaining in popularity. Reduced postoperative pain, decreased postoperative narcotic requirement, decreased length of hospital stay, lower wound-related complications, and improved cosmesis have transformed minimally invasive liver resection to become the preferred approach when technically feasible. In recent years, minimally invasive major hepatectomy is increasingly performed worldwide, especially at major hepatobiliary centers. More hepatobiliary surgeons are interested in embracing laparoscopic or robotic liver resection in an effort to improve patient results. Herein, we describe outcomes, technical approaches, and current literature relating to minimally invasive hepatic resection.
Laparoscopy-assisted versus open and pure laparoscopic approach for liver resection and living donor hepatectomy: a systematic review and meta-analysis
2018, HPB
Citation Excerpt :
For hybrid vs. OLR comparison, 16 articles were included (7 in the resection subgroup11–13,22–25 and 9 in living donation subgroup17,26–33). For hybrid vs. PLLR comparison, 10 articles were included (8 in resection subgroup11,12,22,25,34–37 and 2 in living donation subgroup29,38). In 5 articles both comparisons were done11,22,12,25,29 (sTable 1).
Laparoscopy-assisted (hybrid) liver surgery is considered a minimally invasive technique, however there are doubts regarding loss of the benefits of laparoscopy due to the use of an auxiliary incision. The aim of this study was to compare perioperative results of hybrid vs. open and hybrid vs. pure laparoscopic approach to liver resection for focal lesions and living donation.
A systematic review was performed in Medline, EMBASE, Cochrane Library Central and LILACS databases. Perioperative outcomes were analyzed.
21 studies were included. Hybrid vs. open: operative time was lower in open group (mean difference [MD] = 34 min; 95%CI: 22–47; P < 0.001; N = 669). Hybrid technique was associated with a reduction in operative blood loss [MD = −43 ml; 95%CI: −74–(−13); P = 0.005, N = 1738]; shorter hospital stay [MD = −1.9 days; 95%CI: −3.2–(−0.5); P = 0.008; N = 833] and lower morbidity [risk difference (RD) = −0.05; 95%CI: −0.10–(−0.01); P = 0.010; N = 1359]. Hybrid vs. pure laparoscopic: There was no difference regarding blood loss, transfusion rate, hospital stay and morbimortality.
Hybrid technique had perioperative outcomes that were more in keeping with pure laparoscopic outcomes than open surgery. Hybrid liver surgery should be considered a minimally invasive approach.
Fully laparoscopic left hepatectomy – a technical reference proposed for standard practice compared to the open approach: a retrospective propensity score model
2018, HPB
Laparoscopic left hemihepatectomy (LLH) may be an alternative to open (OLH). There are several original variations in the technical aspects of LLH, and no accepted standard. The aim of this study is to assess the safety and effectiveness of the technique developed at Henri Mondor Hospital since 1996.
The technique of LLH was conceived for safety and training of two mature generations of lead surgeons. The technique includes full laparoscopy, ventral approach to the common trunk, extrahepatic pedicle dissection, CUSA^® parenchymal transection, division of the left hilar plate laterally to the Arantius ligament, and ventral transection of the left hepatic vein. The outcomes of LLH and OLH were compared. Perioperative analysis included intra- and postoperative, and histology variables. Propensity Score Matching was undertaken of background covariates including age, ASA, BMI, fibrosis, steatosis, tumour size, and specimen weight.
17 LLH and 51 OLH were performed from 1996 to 2014 with perioperative mortality rates of 0% and 6%, respectively. In the LLH group, two patients underwent conversion to open surgery. Propensity matching selected 10 LLH/OLH pairs. The LLH group had a higher proportion of procedures for benign disease. LLH was associated with longer operating time and less blood loss. Perioperative complications occurred in 30% (LLH) and 10% (OLH) (p = 1). Mortality and ITU stay were similar.
This technique is recommended as a possible technical reference for standard LLH.
Evolution of Laparoscopic Liver Surgery from Innovation to Implementation to Mastery: Perioperative and Oncologic Outcomes of 2,238 Patients from 4 European Specialized Centers
2017, Journal of the American College of Surgeons
First seen as an innovation for select patients, laparoscopic liver resection (LLR) has evolved since its introduction, resulting in worldwide use. Despite this, it is still limited mainly to referral centers. The aim of this study was to evaluate a large cohort undergoing LLR from 2000 to 2015, focusing on the technical approaches, perioperative and oncologic outcomes, and evolution of practice over time.
The demographics and indications, intraoperative, perioperative, and oncologic outcomes of 2,238 patients were evaluated. Trends in practice and outcomes over time were assessed.
The percentage of LLR performed yearly has increased from 5% in 2000 to 43% in 2015. Pure laparoscopy was used in 98.3% of cases. Wedge resections were the most common operation; they were predominant at the beginning of LLR and then decreased and remained steady at approximately 53%. Major hepatectomies were initially uncommon, then increased and reached a stable level at approximately 16%. Overall, 410 patients underwent resection in the posterosuperior segments; these were more frequent with time, and the highest percentage was in 2015 (26%). Blood loss, operative time, and conversion rate improved significantly with time. The 5-year overall survival rates were 73% and 54% for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM), respectively. The 5-year, recurrence-free survival rates were 50% and 37% for HCC and CRLM, respectively.
Since laparoscopy was introduced, a long implementation process has been necessary to allow for standardization and improvement in surgical care, mastery of the technique, and the ability to obtain good perioperative results with safe oncologic outcomes.
Chapter 117 - Living-donor liver transplantation: Indications, outcomes, and surgical considerations
2016, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth Edition
Minimally-invasive liver resection in pediatric patients: Initial experience and outcomes
2016, HPB
Minimally Invasive Liver Resection (MILR) is an evolving procedure in the adult population for benign and malignant lesions, offering less morbidity while maintaining acceptable outcomes. However, there lacks a published MILR experience in the pediatric population besides case reports. This report describes a pediatric MILR experience in terms of pathology, clinical specifics, and patient outcomes.
This is a retrospective review of 36 pediatric patients undergoing MILR for benign and malignant conditions. MILR was performed by pure laparoscopy, hand-assisted laparoscopy, and a hybrid laparoscopic assisted method. Data points reviewed include patient demographics, pathology, operative technique, complications, and recurrence.
Patients with benign (15) and malignant (21) conditions underwent segmentectomy, sectionectomy, or hemihepatectomy by MILR. Thirty-one were completed with pure laparoscopy and 20 underwent hemihepatectomy. Operative time and blood loss correlated with magnitude of resection with five patients requiring a blood transfusion. Complications were minor and included a seroma, port infection, port dehiscence, line infection, and hypertrophic scar. At median follow-up of 12 months (range 6–36 months), there were no mortalities, re-operations, or recurrences.
MILR can be performed in pediatric patients for benign and malignant conditions with good technical and oncologic outcomes and low morbidity.

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Central Surgical AssociationLaparoscopic liver surgery for everyone: The hybrid method

Section snippets

Case 1

Case 2

Technique

Methods

Results

Discussion

Am J Surg

J Am Coll Surg

Surg Clin N Am

J Gastrointest Surg

J Gastrointest Surg

Adv Surg

Am J Transplant

A review of techniques for liver resection

Ann R Coll Surg Engl

Hepatic resections: changing mortality and morbidity

Am Surg

One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery

Br J Surg

Improvement in perioperative outcome after hepatic resection: analysis of 1803 consecutive cases over the past decade

Ann Surg

Hepatic resection in the United States: indications, outcomes, and hospital procedural volumes from a nationally representative database

Arch Surg

Central Surgical Association
Laparoscopic liver surgery for everyone: The hybrid method